Journal of Shoulder and Elbow Surgery

Computer navigation leads to more accurate glenoid targeting during total shoulder arthroplasty compared with 3-dimensional preoperative planning alone


      Commercially available preoperative planning software is now widely available for shoulder arthroplasty. However, without the use of patient-specific guides or intraoperative visual guidance, surgeons have little in vivo feedback to ensure proper execution of the preoperative plan. The purpose of this study was to assess surgeons' ability to implement a preoperative plan in vivo during shoulder arthroplasty.


      Fifty primary shoulder arthroplasties from a single institution were retrospectively reviewed. All surgical procedures were planned using a commercially available software package with both multiplanar 2-dimensional computed tomography and a 3-dimensional implant overlay. Following registration of intraoperative visual navigation trackers, the surgeons (1 attending and 1 fellow) were blinded to the computer navigation screen and attempted to implement the plan by simulating placement of a central-axis guide pin. Malposition was assessed (>4 mm of displacement or >10° error in version or inclination). Data were then blinded, measured, and evaluated.


      Mean displacement from the planned starting point was 3.2 ± 2.0 mm. The mean error in version was 6.4° ± 5.6°, and the mean error in inclination was 6.6° ± 4.9°. Malposition was observed in 48% of cases after preoperative planning. Malposition errors were more commonly made by fellow trainees vs. attending surgeons (58% vs. 38%, P = .047).


      Despite preoperative planning, surgeons of various training levels were unable to reproducibly replicate the planned component position consistently. Following completion of fellowship training, significantly less malposition resulted. Even in expert hands, the orientation of the glenoid component would have been malpositioned in 38% of cases. This study further supports the benefit of guided surgery for accurate placement of glenoid components, regardless of fellowship training.

      Level of evidence


      To read this article in full you will need to make a payment


        • Allam Y.
        • Silbermann J.
        • Riese F.
        • Greiner-Perth R.
        Computer tomography assessment of pedicle screw placement in thoracic spine: comparison between free hand and a generic 3D-based navigation techniques.
        Eur Spine J. 2013; 22: 648-653
        • Briem D.
        • Ruecker A.H.
        • Neumann J.
        • Gebauer M.
        • Kendoff D.
        • Gehrke T.
        • et al.
        3D fluoroscopic navigated reaming of the glenoid for total shoulder arthroplasty (TSA).
        Comput Aided Surg. 2011; 16: 93-99
        • Domb B.G.
        • El Bitar Y.F.
        • Sadik A.Y.
        • Stake C.E.
        • Botser I.B.
        Comparison of robotic-assisted and conventional acetabular cup placement in THA: a matched-pair controlled study.
        Clin Orthop Relat Res. 2014; 472: 329-336
        • Farron A.
        • Terrier A.
        • Büchler P.
        Risks of loosening of a prosthetic glenoid implanted in retroversion.
        J Shoulder Elbow Surg. 2006; 15: 521-526
        • Gauci M.O.
        • Boileau P.
        • Baba M.
        • Chaoui J.
        • Walch G.
        Patient-specific glenoid guides provide accuracy and reproducibility in total shoulder arthroplasty.
        Bone Joint J. 2016; 98-B: 1080-1085
        • Gutiérrez S.
        • Greiwe R.M.
        • Frankle M.A.
        • Siegal S.
        • Lee W.E.
        Biomechanical comparison of component position and hardware failure in the reverse shoulder prosthesis.
        J Shoulder Elbow Surg. 2007; 16: S9-S12
        • Hamilton M.A.
        • Polakovic S.
        • Saadi P.
        • Jones R.B.
        • Parsons I.M.
        • Cheung E.V.
        Evaluation of preoperative implant placement in total shoulder arthroplasty.
        Bull Hosp Jt Dis (2013). 2015; 73: S47-S51
        • Heylen S.
        • Van Haver A.
        • Vuylsteke K.
        • Declercq G.
        • Verborgt O.
        Patient-specific instrument guidance of glenoid component implantation reduces inclination variability in total and reverse shoulder arthroplasty.
        J Shoulder Elbow Surg. 2016; 25: 186-192
        • Ho J.C.
        • Sabesan V.J.
        • Iannotti J.P.
        Glenoid component retroversion is associated with osteolysis.
        J Bone Joint Surg Am. 2013; 95: e82
        • Hopkins A.R.
        • Hansen U.N.
        • Amis A.A.
        • Emery R.
        The effects of glenoid component alignment variations on cement mantle stresses in total shoulder arthroplasty.
        J Shoulder Elbow Surg. 2004; 13: 668-675
        • Iannotti J.P.
        • Greeson C.
        • Downing D.
        • Sabesan V.
        • Bryan J.A.
        Effect of glenoid deformity on glenoid component placement in primary shoulder arthroplasty.
        J Shoulder Elbow Surg. 2012; 21: 48-55
        • Iannotti J.P.
        • Weiner S.
        • Rodriguez E.
        • Subhas N.
        • Patterson T.E.
        • Jun B.J.
        • et al.
        Three-dimensional imaging and templating improve glenoid implant positioning.
        J Bone Joint Surg Am. 2015; 97: 651-658
        • Jacquot A.
        • Gauci M.-O.
        • Chaoui J.
        • Baba M.
        • Deransart P.
        • Boileau P.
        • et al.
        Proper benefit of a three dimensional pre-operative planning software for glenoid component positioning in total shoulder arthroplasty.
        Int. Orthop. 2018; 42: 2897-2906
        • Kircher J.
        • Wiedemann M.
        • Magosch P.
        • Lichtenberg S.
        • Habermeyer P.
        Improved accuracy of glenoid positioning in total shoulder arthroplasty with intraoperative navigation: a prospective-randomized clinical study.
        J Shoulder Elbow Surg. 2009; 18: 515-520
        • Mansat P.
        • Briot J.
        • Mansat M.
        • Swider P.
        Evaluation of the glenoid implant survival using a biomechanical finite element analysis: influence of the implant design, bone properties, and loading location.
        J Shoulder Elbow Surg. 2007; 16: S79-S83
        • Miyasaka T.
        • Kurosaka D.
        • Saito M.
        • Omori T.
        • Ikeda R.
        • Marumo K.
        Accuracy of computed tomography-based navigation-assisted total knee arthroplasty: outlier analysis.
        J Arthroplasty. 2017; 32: 47-52
        • Mollon B.
        • Mahure S.A.
        • Roche C.P.
        • Zuckerman J.D.
        Impact of scapular notching on clinical outcomes after reverse total shoulder arthroplasty: an analysis of 476 shoulders.
        J Shoulder Elbow Surg. 2017; 26: 1253-1261
        • Nashikkar P.S.
        • Scholes C.J.
        • Haber M.D.
        Computer navigation re-creates planned glenoid placement and reduces correction variability in total shoulder arthroplasty: an in vivo case-control study.
        J Shoulder Elbow Surg. 2019; 28: e398-e409
        • Nguyen D.
        • Ferreira L.M.
        • Brownhill J.R.
        • King G.J.W.
        • Drosdowech D.S.
        • Faber K.J.
        • et al.
        Improved accuracy of computer assisted glenoid implantation in total shoulder arthroplasty: an in-vitro randomized controlled trial.
        J Shoulder Elbow Surg. 2009; 18: 907-914
        • Roche C.P.
        • Stroud N.J.
        • Martin B.L.
        • Steiler C.A.
        • Flurin P.-H.
        • Wright T.W.
        • et al.
        The impact of scapular notching on reverse shoulder glenoid fixation.
        J Shoulder Elbow Surg. 2013; 22: 963-970
        • Scalise J.J.
        • Codsi M.J.
        • Bryan J.
        • Brems J.J.
        • Iannotti J.P.
        The influence of three-dimensional computed tomography images of the shoulder in preoperative planning for total shoulder arthroplasty.
        J Bone Joint Surg Am. 2008; 90: 2438-2445
        • Schoch B.S.
        • Wright T.W.
        • Zuckerman J.D.
        • Bolch C.
        • Flurin P.-H.
        • Roche C.
        • et al.
        Glenoid component lucencies are associated with poorer patient-reported outcomes following anatomic shoulder arthroplasty.
        J Shoulder Elbow Surg. 2019; 28: 1956-1963
        • Simovitch R.W.
        • Zuckerman J.D.
        • Wright T.W.
        • Flurin P.-H.
        • Roche C.
        Impact of scapular notching on reverse total shoulder arthroplasty outcomes—5 year minimum follow-up.
        J Shoulder Elbow Surg. 2019; 28: e204-e205
        • Stübig T.
        • Petri M.
        • Zeckey C.
        • Hawi N.
        • Krettek C.
        • Citak M.
        • et al.
        3D navigated implantation of the glenoid component in reversed shoulder arthroplasty. Feasibility and results in an anatomic study.
        Int J Med Robot. 2013; 9: 480-485
        • Throckmorton T.W.
        • Gulotta L.V.
        • Bonnarens F.O.
        • Wright S.A.
        • Hartzell J.L.
        • Rozzi W.B.
        • et al.
        Patient-specific targeting guides compared with traditional instrumentation for glenoid component placement in shoulder arthroplasty: a multi-surgeon study in 70 arthritic cadaver specimens.
        J Shoulder Elbow Surg. 2015; 24: 965-971
        • Venne G.
        • Rasquinha B.J.
        • Pichora D.
        • Ellis R.E.
        • Bicknell R.
        Comparing conventional and computer-assisted surgery baseplate and screw placement in reverse shoulder arthroplasty.
        J Shoulder Elbow Surg. 2015; 24: 1112-1119
        • Verborgt O.
        • De Smedt T.
        • Vanhees M.
        • Clockaerts S.
        • Parizel P.M.
        • Van Glabbeek F.
        Accuracy of placement of the glenoid component in reversed shoulder arthroplasty with and without navigation.
        J Shoulder Elbow Surg. 2011; 20: 21-26
        • Werner B.S.
        • Hudek R.
        • Burkhart K.J.
        • Gohlke F.
        The influence of three-dimensional planning on decision-making in total shoulder arthroplasty.
        J Shoulder Elbow Surg. 2017; 26: 1477-1483